Boyko, Stanley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
StanleyW, Bo ko
Date of Death Age If Veteran of U.S. Armed Forces,
No 71 War or Dates y _ 1949-66
Place of Death Hospital, Institution or
City, Town or Village Sarato a Springs' Street Addressrnngrimps
4111 Manner of Death x❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ ndetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
J. Pas
Address
172 Caroline St re
Death Certificate Filed District Number egister umber
City, Town or Village Saratoga springs 454
Date Cemetery or Crematory
F:: ❑Burial December
Cremation Address
Date Place Removed
❑Removal and/or Held
and/or Address
a5Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 00267
Address
6
Name of Funeral Firm Making ispositi12866
on o to om '
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of ifte human remain escr' ed abov as in icated.
Date Issued 12/1/9 7 Registrar of Vital Statistics
(si
<> District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permiton:,/►
Date of Dispositior�/�L� Place of Disposition
(address)
LU
L1E: (section) (lot n mr}� ( rave number)
0 Name of Sexto or Person i Charge of Premises ,��G)4q�p
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61